创伤性膈肌破裂的表现及诊治中值得注意的问题

The problems in manifestation,diagnosis and treatment of traumatic diaphragmatic rupture

目的探讨创伤性膈肌破裂（TDR）的表现及诊治中值得注意问题。方法笔者回顾性分析1980年1月～2015年1月收治TDR 54例的临床资料,男性43例,女性11例;年龄7～68岁,平均（36±16.2）岁。左侧膈肌破裂48例,右侧6例。开放性、闭合性膈肌破裂膈疝发生率各为10.0%（1/10）和90.9%（40/44）（P〈0.01）。结果患者伤后或入院24h内未能确诊31例占57.4%,院内、外延误诊断率各为14.8（8/54）%和42.6%（23/54）（P〈0.01）;X线、CT、B超对膈疝的检出率各为51.4%（19/37）、87.5%（28/32）和56.3%（9/16）,其中23例经2种以上检查手段确诊,CT组与X线、B超组比较差异均有统计学意义（P〈0.05）;41例膈疝术中证实均难自行还纳,其中29.3%与胸腔形成粘连,9例因疝入脏器破裂或绞窄、坏死行手术修补或切除。本组治愈51例（94.4%）,因创伤性休克、重型颅脑损伤合并多器官功能衰竭死亡3例（5.6%）,其ISS平均值为42.4分。结论伤后出现胸腹双腔症/症候群和膈疝影像学特征是诊断TDR的主要依据,早期诊断、合理选择手术方法、积极处理合并伤是临床关注的重点。

Objective To investigate the problems in manifestation, diagnosis and treatment of traumatic diaphragmatic rupture（TDR）. Methods The clinical data of 54 TDR patients from Jan. 1980 to Jan. 2015 were retrospectively analyzed. There were 43 males and 11 females, with an average age of 36 ＋ 16. 2 （ range, 7-68 year old）. There were 48 cases of left phragmatic rupture and 6 cases of right phragmatic rupture. The rate of open and closed diaphragmatic rupture were 10. 0% （1/10） and 90. 9% {40/44} ,respectively{ P 〈 0. 01 ）. Results Thirty- one patients were not diagnosed within 24 hours following admission （ 57.4% ）. The rate of misdiagnosis and de- layed diagnosis were 14. 8% （ 8/54 ） and 42. 6% （ 23/54 ） , respectively （ P 〈 0. 01 ）. The diagnosed rate of X ray, CT, and ultrasonic examination were 51.4% （ 19/37 ）, 87.5% （28/32） and 56. 3% （9/16）, respectively. Twenty- three cases were diagnosed by 2 or 3 examinations. There were signification differences between CT examination and X ray examination or ultrasonic examination （ P 〈 0.051 - Forty-one diaphragmatic hernia cases were found hard to return during operations and 29. 3% of them adhered with thoracic cavity. Nine cases were treated by surgery be- cause of necrosis or strangulation. In this study,51 cases were cured{ 94.4% ） ,3 cases died because of traumatic shock, severe head injury, and multiple organ dysfunction failure with an average injury severity score （ ISS ） of 42. 4 points. Conclusion The main diagnosis basis of TDR is double cavities after trauma and imaging examination. Early diagnosis,reasonable choices of surgical methods and active management of associated injuries are main con- cerns in clinical application.